NOTICE OF PRIVACY PRACTICES PATIENT’S RIGHTS & RESPONSIBILITIES

This notice describes how medical information about you may be used and disclosed by 20Twenty Eyecare and how you can get access to this information. Please review this document carefully.

Your Rights

The following is a brief summary of your rights. A more detailed description of each right is also included in
this document.
• Get a copy of your paper or electronic health record
• Request correction of your paper or electronic health record
• Request confidential communication
• Ask us to limit the information we share
• Get a list of those with whom we’ve shared your information
• Get a copy of this privacy notice
• Choose someone to act for you
• File a complaint if you believe your privacy rights have been violated

Your Choices

You have some choices in the way that 20Twenty Eyecare uses and shares information as we:
• Tell family and friends about your condition
• Provide disaster relief
• Include your information in a hospital directory
• Provide mental health care
• Market our services
• Raise funds

Our Uses and Disclosures

20Twenty Eyecare may use and share your information as we:
• Treat you and coordinate your care
• Run our organization
• Bill for your services
• Help with public health and safety issues
• Do research
• Comply with the law
• Respond to organ and tissue donation requests
• Work with a medical examiner or funeral director
• Address workers’ compensation, law enforcement, and other government requests
• Respond to lawsuits and legal actions

A Word About United States (U.S.) Federal and State Law

20Twenty Eyecare may use, process, and disclose your medical information in accordance with U.S. law. U.S.
federal and state laws require 20Twenty Eyecare to protect your medical information and federal law
requires us to describe to you how we handle that information. When federal and state privacy laws are
different and conflict, and the state law is more protective of your information or provides you with greater
access to your information, then we will follow state law. For example, where we have identified specific
state law requirements in this notice, the referenced 20Twenty Eyecare location will follow the more
protective state law requirements.

Your Rights

When it comes to your health information, you have certain rights. This section explains your rights and some
of 20Twenty Eyecare’s responsibilities to help you.

Get an electronic or paper copy of your medical record

• You can ask to see or get an electronic or paper copy of your medical record and other health information
we have about you. If you would like, we also can send this information in either paper or electronic form to
another person you identify in your request. All records are uploaded to each patient’s portal.

Ask 20Twenty Eyecare to correct your medical record

• You can ask us to correct health information about you that you think is incorrect or incomplete.
• We may say “no” to your request, but we’ll tell you why in writing within 60 days.

Request confidential communications

• You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a
different address.
• We will say “yes” to all reasonable requests.

Ask 20Twenty Eyecare to limit what we use or share

• You can ask us not to use or share certain health information for treatment, payment, or 20Twenty
Eyecare’s operations. We are not required to agree to your request, and we may say “no” if it would be
harmful or compromise your care.
• If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that
information for the purpose of payment or our operations with your health insurer. We will say “yes” unless
a law requires us to share that information.

Get a list of those with whom we’ve shared information

• You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to
the date you ask, who we shared it with, and why.
• We will include all the disclosures except for those about treatment, payment, and health care operations,
and certain other disclosures (such as any you asked us to make). We will provide one accounting a year for
free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.

Get a copy of this privacy notice

• You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice
electronically. 20Twenty Eyecare will provide you with a paper copy promptly.

Choose someone to act for you

• If you have given someone medical power of attorney or if someone is your legal guardian, that person can
exercise your rights and make choices about your health information.
• We will make sure the person has this authority and can act for you before we take any action.

File a complaint if you feel your rights are violated

• You can complain if you feel we have violated your rights by contacting us.
• You can file a complaint with the U.S. Department of Health & Human Services, Office for Civil Rights by
sending a letter to 200 Independence Avenue SW, Washington, DC 20201, calling 1-800-368-1019, or visiting
www.hhs.gov/ocr/privacy/hipaa/complaints/We will not retaliate against you for filing a complaint.

Calling, Texting, and Emailing

We may contact you about your health care using the phone numbers and email addresses that you provide
us. This may include using an automated phone dialing system, pre-recorded or synthetic voice messages,
texting, or email. When we contact you in this manner, you will be given the opportunity to opt out of
receiving similar communications going forward. Our messages may include, but are not limited to,
information about appointment reminders, discharge planning, billing, prescription reminders, research
opportunities, and regulatory notices provided in lieu of first-class mail. Because any texts and emails would
not be encrypted, there is a risk that someone else could read or access these messages. We therefore take
steps to limit the amount of protected health information that they contain. If you do not wish to receive
these types of text or email messages, please let us know, and we will honor your request.

Your Choices

For certain health information, you can tell us your choices about what we share.
If you have a clear preference for how we share your information in the situations described below, talk to
us. Tell us what you want us to do, and we will follow your instructions.
In these cases, you have both the right and choice to tell us to:
• Share information with your family, close friends, or others involved in your care
• Share information in a disaster relief situation
• Include your information in a hospital directory
If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share
your information if we believe it is in your best interest. We may also share your information when needed to
lessen a serious and imminent threat to health or safety.

Additional Applicable State Law Requirements

Montana law generally requires patient consent to share health information with family members or friends,
except as required or authorized by law. In these cases we never share your information unless you give us
written permission:
• Marketing purposes
• 20Twenty Eyecare does not sell or rent our patients’ names or addresses to any organization outside of
20Twenty Eyecare.

Our Uses and Disclosures

How does 20Twenty Eyecare typically use or share your health information? We typically use or share your
health information in the following ways: To treat you and coordinate your care. We can use your health
information and share it with other professionals who are treating you and to help coordinate your care. We
can use and share your health information to run our practice, improve your care, and contact you when
necessary. We may also share health information with another health care provider who has treated you, or
to your insurance company. This may be done when the information is needed for health care operations of
the health care provider or the insurance company, such as quality improvement activities, evaluations of
health care professionals, and state and federal regulatory reviews.

To bill for your services

We can use and share your health information to bill and get payment from health plans or other entities.

How else can 20Twenty Eyecare use or share your health information?

We are allowed or required to share your information in other ways—usually in ways that contribute to the
public good, such as public health and research. We have to meet many conditions in the law before we can
share your information for these purposes. For more information, you can go to this online link:
www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html

Help with public health and safety issues

We can share health information about you for certain situations such as:
• Preventing disease
• Helping with product recalls
• Reporting adverse reactions to medications
• Reporting suspected abuse, neglect, or domestic violence
• Preventing or reducing a serious threat to anyone’s health or safety

Do research

We can use or share your information for health research.

Comply with the law

We will share information about you if state or federal laws require it, including with the Department of
Health and Human Services if it requests to see that we’re complying with federal privacy law.

Respond to organ and tissue donation requests

20Twenty Eyecare can share health information about you with organ procurement organizations.

20Twenty Eyecare can use or share health information about you:

• For workers’ compensation claims
• For law enforcement purposes or with a law enforcement official
• With health oversight agencies for activities authorized by law
• For special government functions such as military, national security, and presidential protective services

20Twenty Eyecare’s Responsibilities

• We are required by law to maintain the privacy and security of your protected health information.
• We will let you know promptly if a breach occurs that may have compromised the privacy or security of
your information.
• We must follow the duties and privacy practices described in this notice and give you a copy of it.
• We will not use or share your information other than as described here unless you tell us we can in writing.
If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.
For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html

Changes to the Terms of This Notice

20Twenty Eyecare can change the terms of this notice, and the changes will apply to all information we have
about you. The new notice will be available upon request, in our office, and on our web site at
hwww.20Twentymt.com
• Complaints or Concerns: You are welcome to raise any complaints or concerns to 20Twenty Eyecare by
contacting 20Twenty Eyecare’s Data Protection Officer at info@twentymt.com. You also have the right to
lodge a complaint with a supervisory authority.

Contact Information

If you want to file a complaint, express concerns, or further inquire about 20Twenty Eyecare’s use or
disclosure of health information, please contact the 20Twenty Eyecare Privacy Officer by calling 406-522-
8888 or send an email to info@20twentymt.com.

Effective Date

The Effective Date of this Notice is 08/01/13.

Discrimination is Against the Law

20Twenty Eyecare complies with applicable Federal civil rights laws and does not discriminate on the basis of
race, color, creed, religion, gender, marital status, sexual orientation, gender identity or expression, veteran’s
status, status with regard to public assistance, national origin, disability, or age in admission to, participation
in, or receipt of the services and benefits under any of its programs and activities.

20Twenty Eyecare:

• Provides free aids and services to people with disabilities to communicate effectively, such as:
Written information in other formats (large print, audio, accessible electronic formats, other formats).
If you need these services, please contact the office. If you believe that 20Twenty Eyecare has failed to
provide these services or discriminated in another way on the basis of race, color, creed, religion, gender,
marital status, sexual orientation, gender identity or expression, veteran’s status, status with regard to public
assistance, national origin, disability, or age in admission to, participation in, or receipt of the services and
benefits under any of its programs and activities, you can file a grievance with any manager at 406-522-8888.
You can file a grievance in person or by mail.

Experience is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health & Human Services, Office for Civil
Rights. File electronically through the Complaint Portal at: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf
File by mail: U.S. Department of Health & Human Services, 200 Independence Avenue SW, Room 509F,
HHH Building, Washington, DC 20201
File by phone: 1-800-368-1019
Complaint files are available at http://www.hhs.gov/ocr/office/file/index.html